NCG guidelines for endometrial cancer
Transcript of NCG guidelines for endometrial cancer
NCG GUIDELINES FOR ENDOMETRIAL CANCER
Treatment Algorithm: Endometrial Cancer
Postmenopausal/ Abnormal Vaginal Bleeding (PAP smear as indicated)
Transvaginal USG for Endometrial Thickness (ET)
Negative for malignancy
Endometrial biopsy +/- Hysteroscopy
Endometrial cancer
<5mm
Close observation or an immediate biopsy at discretion of clinician
Management by a general gynecologist
Atypical Hyperplasia
≥5mm/Mass in Endometrial cavity regardless of thickness
Histopathology +/-IHC
$$: PET-CT should not be done in early lesions.
Endometrial cancer
Clinically early stage
Imaging – X ray chest
USG or MRI or CE-CT scan
(Abdomen & pelvis)
Advanced stage
Surgery**
CECT Abdomen + Pelvis+
Thorax or whole body PET-CT$$
Operable Not suitable for
surgery
Chemotherapy 3-4 #
Reassess for Surgery
Detailed Histopathology Report including IHC as indicated
Suitable for Surgery** Not suitable for Surgery
Continue chemotherapy –Total
6#
Palliative RT or hormonal Rx
Palliative care
* TH+ BSO is the minimum standard. Lymph nodal dissection in patients with high risk features based on pre- or intra-operative assessment ** Table 1: Surgery
StageIA, G1 TH BSO#
Stage IA G2/3, IB G1 TH BSO +/-Pelvic Lymphadenectomy
Stage IB G2/3 TH BSO pelvic lymphadenectomy +/-paraaortic lymphadenectomy
Stage II TH BSO/Type 2 Radical Hysterectomy &pelvic lymphadenectomy ± paraaortic lymphadenectomy
Serous histology TH BSO + pelvic and paraaortic lymphadenectomy and infracolic omentectomy
#Normal appearing ovaries may be preserved in a young patient for fertility preservation after counselling
and explaining associated risks.
Fertility preservation: In young patients, disease limited to endometrium, Grade I, endometriod histology,
ER/PR Positive, and P53 negative. Counselling for the associated risks is mandatory.A pre-treatment MRI is
mandatory to evaluate local extent of disease and status of ovaries. Treatment is done by high dose
progesterone with frequent response monitoring at 2-3 monthly interval. The efficacy of progesterone
containing IUDs alone is not proven in invasive endometrial cancer.
TH BSO: Total Hysterectomy Bilateral Salpingoophorectomy (Open/ Laparoscopic/ Robotic)
Post-operative Risk Group Stratification for Adjuvant Therapy ^^
Risk Group Description
Low risk Stage I endometrioid, grade 1–2, <50% myometrial invasion, LVSI negative
Intermediate risk Stage I endometrioid, grade 1–2, ≥50% myometrial invasion, LVSI negative
High-Intermediate risk Stage I endometrioid, grade 3, <50% myometrial invasion, regardless of LVSI status Stage I endometrioid, grade 1–2, LVSI unequivocally positive, regardless of depth of invasion
High Risk Stage I endometrioid, grade 3, >50% myometrial invasion, regardless of LVSI status Stage II Stage III endometrioid, no residual disease Non endometrioid (serous or clear cell or undifferentiated carcinoma, or carcinosarcoma)
Advanced Stage III residual disease and stage IVA
Metastatic Stage IVB
^^: ESMO-ESGO-ESTRO Consensus Guidelines
FIGO 2009 Staging for Cancer Endometrium
Stage I Tumor confined to the corpus uteri
IA No or less than half myometrial invasion
IB Invasion equal to or more than half of the myometrium
Stage II Tumor invades cervical stroma, but does not extend beyond the uterus
Stage III Local and/or regional spread of the tumor
IIIA Tumor invades the serosa of the corpus uteri and/or adnexae#
IIIB Vaginal and/or parametrial involvement#
IIIC Metastases to pelvic and/or para-aortic lymph nodes#
IIIC1 Positive pelvic nodes
IIIC2 Positive para-aortic lymph nodes with or without positive pelvic lymph nodes
Stage IV Tumor invades bladder and/or bowel mucosa, and/or distant metastases
Stage IVA Tumor invasion of bladder and/or bowel mucosa
Stage IV B Distant metastases, including intra-abdominal metastases and/or inguinal lymphnodes
Each Stage includes GI, G2, or G3 depending upon the histological grade of the tumor.
*Endocervical glandular involvement alone should be considered as Stage I
# Positive cytology has to be reported separately without changing the stage
WHO Histological classification
Type I Histology Endometrioid Adenocarcinoma
Type II Histology Serous Mucinous Clear cell Carcinosarcoma Undifferentiated
Adequate Surgery**
IA IB
G1/G2 G3 G1/G2 G3
LVSI LVSI
N Y/NR
Observe VBT EBRT VBT or EBRT
N Y/NR
VBT
N Y/NR
LVSI
N Y/NR
EBRT
LVSI
II
EBRT+VBT
Stage I & II EEC
Inadequate Surgery ***
IA IB
G1/G2 G3 G1/G2 G3
LVSI
N Y/NR
Observe EBRT EBRT or VBT
II
EBRT+VBT EBRT
Stage I & II EEC
LVSI LVSI
N Y/NR
VBT
Consider staging
surgery
Adjuvant treatment
as per ‘adequate
surgery’ guidelines
***Unilateral Salpingo-oophorectomy/ No Salpingo-oophorectomy/Lymph node dissection not
done.
Adequate Surgery: Stage III EEC
IIIA/B IIIC
IIIC1 IIIC2
Chemotherapy (Paclitaxel and Carboplatin): 4- 6 Cycles +/- Radiation
therapy (Sequencing can be as per Institutional Practice)
Stage IV: EEC
IV A IVB
lndividualisation of treatment Chemotherapy (Paclitaxel 175mg/m2
+Carboplatin AUC 5-6 x 6 cycles) +/-Debulking Sx
Followed by Pelvic +/-Para-aortic RT
Chemotherapy (Paclitaxel 175mg/m2+ Carboplatin AUC 5-6x 6 cycles)
+/- Palliative RT / Symptomatic treatment Hormone therapy if ER/PR +ve
Type II Histology (serous, clear cell, carcinosarcoma, mucinous undifferentiated)
Adequate Surgery: Stage I/II
Clinically Stage III/IV
Yes No
Chemotherapy (Paclitaxel 175mg/m2+ Carboplatin AUC5-6x 4 cycles)
+/- Radiotherapy (brachy and/or EBRT) Chemotherapy +/- Interval Surgery+/-pall RT
lnoperable Ca Endometrium
Pelvic RT+ Brachytherapy +/- Chemotherapy +/ - Hormone Therapy!
Follow up for loco-regional or distant Recurrence and treat accordingly
!: If ER/PR we consider megestrol acetate 160 mg/ day or Aromatase Inhibitor (example letrozole 2.5 mg /day)
Cytoreductive surgery with the
goal to achieve complete
cytoreduction
Surgery feasible
Unfit for Surgery
Early
Advanced
Pelvic EBRT +Brachytherapy Chemotherapy (Paclitaxel 175mg/m2+ Carboplatin AUC5-6x 4 cycles
f/b Pelvic EBRT +/- Para-aortic EBRT
+Brachytherapy
Palliative RT/Palliative CT and/or
hormonal therapy
Radical RT+/- CT
Unresectable Resectable
ectable
Distant Metastasis Local Recurrence
Follow Up Algorithm
Physical Exam: 3- 4 monthly for 2 years, 6 monthly for next 3 years, annually after 5 years Vaginal cytology in patients who have not received radiotherapy
I Imaging may be considered as per clinical indications
Prior RT
Yes No
Consider surgery in selected
cases+/-chemotherapy and/or
hormonal therapy
!:IfER/PR+veconsidermegestrolacetate160mg/day or AromataseInhibitor(exampleletrozole2.5mg/day)
CT/ Hormone Therapy! +/- Palliative RT (Surgery may be considered in patients withisolated metastasis with long disease-free interval)
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